Personal Choice or Predestined? The Road to Specialty Choice
Personal Choice ˜˚ 2020€¦ · This Summary of Benefits booklet gives you a summary of what...
Transcript of Personal Choice ˜˚ 2020€¦ · This Summary of Benefits booklet gives you a summary of what...
Personal Choice 65SM PPO
H3909Y0041_H3909_PC_20_77038_M Accepted 9/2/2019
2020Summary of BenefitsEffective January 1, 2020 through December 31, 2020
• Personal Choice 65SM Prime Rx PPO• Personal Choice 65SM Medical-Only PPO• Personal Choice 65SM Rx PPO
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This Summary of Benefits booklet gives you a summary of what Personal Choice 65SM
Prime Rx PPO, Personal Choice 65SM Medical-Only PPO, and Personal Choice 65SM
Rx PPO cover and what you pay.
Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,
and Personal Choice 65SM Rx PPO are Medicare Advantage PPO (Preferred Provider
Organization) plans. With a PPO plan, members don’t have to choose a PCP and can
go to doctors in or out of the plan’s network. If members use out-of-network doctors,
hospitals, or other health care providers, they will pay more for their services.
If you want to compare our plans with other available Medicare health plans,
ask the other plan(s) for their Summary of Benefits booklet. Or, use the Medicare Plan
Finder at www.medicare.gov.
If you want to know more about the coverage and costs of Original Medicare,
look in your current “Medicare and You” handbook. View it online at
www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24
hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Sections of this booklet
• Monthly Premium, Deductible, Limits on How Much You Pay
for Covered Services
• Covered Medical and Hospital Benefits
• Prescription Drug Benefits for Personal Choice 65SM Prime Rx PPO
and Personal Choice 65SM Rx PPO• Optional Supplemental Benefits (Choice and Choice Plus Programs)
You must pay an extra premium for these benefits.
Who can join?
To join Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,
and Personal Choice 65SM Rx PPO, you must be entitled to Medicare Part A, be enrolled
in Medicare Part B, and live in our service area.
The service area for Personal Choice 65SM Medical-Only PPO is Bucks and Philadelphia
counties in Pennsylvania.
The service area for Personal Choice 65SM Prime Rx PPO and Personal Choice 65SM Rx
PPO is Bucks, Chester, Delaware, Montgomery, and Philadelphia counties
in Pennsylvania.
This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage or go online at www.ibxmedicare.com.
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Which doctors, hospitals, and pharmacies can I use?
Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,
and Personal Choice 65SM Rx PPO have a network of doctors, hospitals, pharmacies,
and other providers. If you use the providers that are not in our network, a higher cost-
sharing may apply. Personal Choice 65SM Prime Rx PPO and Personal Choice 65 Rx
PPO have a preferred pharmacy network; cost-sharing for drugs may vary depending on
the pharmacy you use. To view our list of network providers and pharmacies (Provider/
Pharmacy Directory),
please visit www.ibxmedicare.com.
Personal Choice 65SM Prime Rx PPO and Personal Choice 65SM Rx PPO cover
Part D drugs. In addition, the plans cover Part B drugs such as chemotherapy
and some other drugs administered by your provider. You can see our complete plan
Formulary (List of Covered Drugs) and any restrictions on our website,
www.ibxmedicare.com.
Personal Choice 65SM Medical-Only PPO covers Part B drugs, including chemotherapy
and some other drugs administered by your provider.
However, the plan does not cover Part D prescription drugs.
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Monthly Plan PremiumPersonal Choice 65SM Prime Rx PPOIf you live in… And you have…
Personal Choice 65SM
Prime Rx PPOPersonal Choice 65SM Prime Rx PPO with Choice
Personal Choice 65SM
Prime Rx PPO with Choice Plus
You pay…
Chester, Delaware, or Montgomery County
$0 $12 $25
Bucks or Philadelphia Coun-ty
$0 $12 $25
Personal Choice 65SM Medical-Only PPOIf you live in… And you have…
Personal Choice 65SM Medical-Only PPO
Personal Choice 65SM
Medical-Only PPO with Choice
Personal Choice 65SM
Medical-Only PPO with Choice Plus
You pay…
Chester, Delaware, or Montgomery County
n/a n/a n/a
Bucks or Philadelphia Coun-ty
$184 $196 $209
Personal Choice 65SM Rx PPOIf you live in… And you have…
Personal Choice 65SM Rx PPO
Personal Choice 65SM Rx PPO with Choice
Personal Choice 65SM Rx PPO with Choice Plus
You pay…
Chester, Delaware, or Montgomery County
$159 $171 $184
Bucks or Philadelphia Coun-ty
$288 $300 $313
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Deductible This plan has a $1,000 deductible for covered medi-
cal services received from out-of-network providers.
Does not apply to preventive services or supplemental
benefits.
This plan does not have a deductible for covered Part
D drugs.
This plan does not have a deductible for covered medical
services.
This plan does not have a deductible for covered
medical services or Part D prescription drugs.
Maximum Out-of-Pocket(the amounts you pay for your premium, Part D prescription drugs and some medical services do not count toward your maximum out-of-pocket amount)
In-Network: $6,700 each year
Our plan has a yearly coverage limit for certain
in-network benefits.
Contact us for the services that apply.
Combined In-Network and Out-of-Network: $10,000 each
year
In-Network: $5,500 each year
Our plan has a yearly coverage limit for certain
in-network benefits.
Contact us for the services that apply.
Combined In-Network and Out-of-Network: $10,000 each
year
In-Network: $5,500 each year
Our plan has a yearly coverage limit for certain
in-network benefits.
Contact us for the services that apply.
Combined In-Network and Out-of-Network: $10,000
each year
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Deductible This plan has a $1,000 deductible for covered medi-
cal services received from out-of-network providers.
Does not apply to preventive services or supplemental
benefits.
This plan does not have a deductible for covered Part
D drugs.
This plan does not have a deductible for covered medical
services.
This plan does not have a deductible for covered
medical services or Part D prescription drugs.
Maximum Out-of-Pocket(the amounts you pay for your premium, Part D prescription drugs and some medical services do not count toward your maximum out-of-pocket amount)
In-Network: $6,700 each year
Our plan has a yearly coverage limit for certain
in-network benefits.
Contact us for the services that apply.
Combined In-Network and Out-of-Network: $10,000 each
year
In-Network: $5,500 each year
Our plan has a yearly coverage limit for certain
in-network benefits.
Contact us for the services that apply.
Combined In-Network and Out-of-Network: $10,000 each
year
In-Network: $5,500 each year
Our plan has a yearly coverage limit for certain
in-network benefits.
Contact us for the services that apply.
Combined In-Network and Out-of-Network: $10,000
each year
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Covered Medical and Hospital BenefitsPersonal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Inpatient Hospital Coverage (1) In-Network: $250 copayment per day, days 1 through
7 per admission for Preferred Hospital
$310 copayment per day,for days 1 through 7 per
admission for Standard Hospital
You pay nothing per day for days 8 and beyond per
admission. No copayment on day of discharge.
Out-of-Network: 30% coinsurance after deductible
In-Network: $250 copayment per day for days 1
through 6 per admission
You pay nothing per day for days 7 and beyond per
admission. No copayment on day of discharge.
$1,500 maximum copayment
per admission
Out-of-Network: 30% coinsurance
In-Network: $250 copayment per day for days 1
through 6 per admission
You pay nothing per day for days 7 and beyond per
admission. No copayment on day of discharge.
$1,500 maximum copayment
per admission
Out-of-Network: 30% coinsurance
Outpatient Hospital Coverage
• Ambulatory Surgical Center (1)
• Outpatient Hospital Facility (1)
• Observation Services
In-Network: $250 copayment
Out-of-Network: 30% coinsurance after deductible
In-Network: $375 copayment for a Preferred Hospital
$475 copayment for a Standard Hospital
Out-of-Network: 30% coinsurance after deductible
In-Network: $375 copayment per stay for a
Preferred Hospital
$475 copayment for a Standard Hospital
Out-of-Network: 30% coinsurance per stay
after deductible
In-Network: $150 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment per stay
Out-of-Network: 30% coinsurance per stay
In-Network: $150 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment per stay
Out-of-Network: 30% coinsurance per stay
Doctor’s Office Visits
• Primary Care Physician
• Specialist
In-Network: $5 copayment for Preferred
primary care physician
$20 copayment for Standard primary care physician
Out-of-Network: 30% coinsurance after deductible
In-Network: $40 copayment for Preferred specialist
$50 copayment for Standard specialist
Out-of-Network: 30% coinsurance after deductible
In-Network: $5 copayment
Out-of-Network: 30% coinsurance
In-Network: $40 copayment
Out-of-Network: 30% coinsurance
In-Network: $5 copayment
Out-of-Network: 30% coinsurance
In-Network: $40 copayment
Out-of-Network: 30% coinsurance
Services with a (1) may require prior authorization.
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Covered Medical and Hospital BenefitsPersonal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Inpatient Hospital Coverage (1) In-Network: $250 copayment per day, days 1 through
7 per admission for Preferred Hospital
$310 copayment per day,for days 1 through 7 per
admission for Standard Hospital
You pay nothing per day for days 8 and beyond per
admission. No copayment on day of discharge.
Out-of-Network: 30% coinsurance after deductible
In-Network: $250 copayment per day for days 1
through 6 per admission
You pay nothing per day for days 7 and beyond per
admission. No copayment on day of discharge.
$1,500 maximum copayment
per admission
Out-of-Network: 30% coinsurance
In-Network: $250 copayment per day for days 1
through 6 per admission
You pay nothing per day for days 7 and beyond per
admission. No copayment on day of discharge.
$1,500 maximum copayment
per admission
Out-of-Network: 30% coinsurance
Outpatient Hospital Coverage
• Ambulatory Surgical Center (1)
• Outpatient Hospital Facility (1)
• Observation Services
In-Network: $250 copayment
Out-of-Network: 30% coinsurance after deductible
In-Network: $375 copayment for a Preferred Hospital
$475 copayment for a Standard Hospital
Out-of-Network: 30% coinsurance after deductible
In-Network: $375 copayment per stay for a
Preferred Hospital
$475 copayment for a Standard Hospital
Out-of-Network: 30% coinsurance per stay
after deductible
In-Network: $150 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment per stay
Out-of-Network: 30% coinsurance per stay
In-Network: $150 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment
Out-of-Network: 30% coinsurance
In-Network: $300 copayment per stay
Out-of-Network: 30% coinsurance per stay
Doctor’s Office Visits
• Primary Care Physician
• Specialist
In-Network: $5 copayment for Preferred
primary care physician
$20 copayment for Standard primary care physician
Out-of-Network: 30% coinsurance after deductible
In-Network: $40 copayment for Preferred specialist
$50 copayment for Standard specialist
Out-of-Network: 30% coinsurance after deductible
In-Network: $5 copayment
Out-of-Network: 30% coinsurance
In-Network: $40 copayment
Out-of-Network: 30% coinsurance
In-Network: $5 copayment
Out-of-Network: 30% coinsurance
In-Network: $40 copayment
Out-of-Network: 30% coinsurance
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Preventive Care In-Network: You pay nothingOut-of-Network: 30% coinsurance
Please refer to the Evidence of Coverage for a com-plete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
In-Network: You pay nothingOut-of-Network: 30% coinsurance
Please refer to the Evidence of Coverage for a com-plete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
In-Network: You pay nothingOut-of-Network: 30% coinsurance
Please refer to the Evidence of Coverage for a complete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
Emergency Care — covered worldwide Worldwide copayment outside the U.S. does not count towards the annual MOOP
In-Network: $90 copayment Not waived if admitted
Out-of-Network: $90 copayment
Not waived if admitted
In-Network: $90 copayment Not waived if admitted
Out-of-Network: $90 copaymentNot waived if admitted
In-Network: $90 copayment Not waived if admitted
Out-of-Network: $90 copaymentNot waived if admitted
Urgently Needed Services — covered worldwideWorldwide copayment outside the U.S. does not count towards the annual MOOP
In-Network and Out-of-Network: $10 copayment in a retail clinic Not waived if admitted
In-Network and Out-of-Network: $50 copayment in an urgent care center Not waived if admitted
Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted
In-Network: $5 copayment in a retail clinic Not waived if admitted
Out-of-Network: $5 copayment in a retail clinic Not waived if admitted
In-Network: $40 copayment in an urgent care center Not waived if admitted
Out-of-Network: $40 copayment in an urgent care center Not waived if admitted
In-Network: $90 copayment per visit outside of U.S. Not waived if admitted
Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted
In-Network: $5 copayment in a retail clinic Not waived if admitted
Out-of-Network: $5 copayment in a retail clinic Not waived if admitted
In-Network: $40 copayment in an urgent care center Not waived if admitted
Out-of-Network: $40 copayment in an urgent care center Not waived if admitted
In-Network: $90 copayment per visit outside of U.S. Not waived if admitted
Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted
Diagnostic Services (1), Lab and Radiology Services (1), and X-rays
• Diagnostic Radiology Services
• Lab Services
• Diagnostic Tests and Procedures
• Outpatient X-rays
In-Network: $45 or $225 copayment depending on serviceOut-of-Network: 30% coinsurance after deductible In-Network: You pay nothing
Out-of-Network: 30% coinsurance after deductible
In-Network: You pay nothingOut-of-Network: 30% coinsurance after deductible
In-Network: $45 copayment for routine radiology services Out-of-Network: 30% coinsurance after deductible for routine radiology services
In-Network: $40 or $175 copayment depending on serviceOut-of-Network: 30% coinsurance In-Network: You pay nothing
Out-of-Network: 30% coinsurance
In-Network: You pay nothingOut-of-Network: 30% coinsurance
In-Network: $40 copayment for routine radiology servicesOut-of-Network: 30% coinsurance for routine radiol-ogy services
In-Network: $40 or $175 copayment depending on serviceOut-of-Network: 30% coinsurance In-Network: You pay nothing
Out-of-Network: 30% coinsurance
In-Network: You pay nothingOut-of-Network: 30% coinsurance
In-Network: $40 copayment for routine radiology services Out-of-Network: 30% coinsurance for routine radiology services
Services with a (1) may require prior authorization.
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Preventive Care In-Network: You pay nothingOut-of-Network: 30% coinsurance
Please refer to the Evidence of Coverage for a com-plete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
In-Network: You pay nothingOut-of-Network: 30% coinsurance
Please refer to the Evidence of Coverage for a com-plete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
In-Network: You pay nothingOut-of-Network: 30% coinsurance
Please refer to the Evidence of Coverage for a complete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
Emergency Care — covered worldwide Worldwide copayment outside the U.S. does not count towards the annual MOOP
In-Network: $90 copayment Not waived if admitted
Out-of-Network: $90 copayment
Not waived if admitted
In-Network: $90 copayment Not waived if admitted
Out-of-Network: $90 copaymentNot waived if admitted
In-Network: $90 copayment Not waived if admitted
Out-of-Network: $90 copaymentNot waived if admitted
Urgently Needed Services — covered worldwideWorldwide copayment outside the U.S. does not count towards the annual MOOP
In-Network and Out-of-Network: $10 copayment in a retail clinic Not waived if admitted
In-Network and Out-of-Network: $50 copayment in an urgent care center Not waived if admitted
Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted
In-Network: $5 copayment in a retail clinic Not waived if admitted
Out-of-Network: $5 copayment in a retail clinic Not waived if admitted
In-Network: $40 copayment in an urgent care center Not waived if admitted
Out-of-Network: $40 copayment in an urgent care center Not waived if admitted
In-Network: $90 copayment per visit outside of U.S. Not waived if admitted
Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted
In-Network: $5 copayment in a retail clinic Not waived if admitted
Out-of-Network: $5 copayment in a retail clinic Not waived if admitted
In-Network: $40 copayment in an urgent care center Not waived if admitted
Out-of-Network: $40 copayment in an urgent care center Not waived if admitted
In-Network: $90 copayment per visit outside of U.S. Not waived if admitted
Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted
Diagnostic Services (1), Lab and Radiology Services (1), and X-rays
• Diagnostic Radiology Services
• Lab Services
• Diagnostic Tests and Procedures
• Outpatient X-rays
In-Network: $45 or $225 copayment depending on serviceOut-of-Network: 30% coinsurance after deductible In-Network: You pay nothing
Out-of-Network: 30% coinsurance after deductible
In-Network: You pay nothingOut-of-Network: 30% coinsurance after deductible
In-Network: $45 copayment for routine radiology services Out-of-Network: 30% coinsurance after deductible for routine radiology services
In-Network: $40 or $175 copayment depending on serviceOut-of-Network: 30% coinsurance In-Network: You pay nothing
Out-of-Network: 30% coinsurance
In-Network: You pay nothingOut-of-Network: 30% coinsurance
In-Network: $40 copayment for routine radiology servicesOut-of-Network: 30% coinsurance for routine radiol-ogy services
In-Network: $40 or $175 copayment depending on serviceOut-of-Network: 30% coinsurance In-Network: You pay nothing
Out-of-Network: 30% coinsurance
In-Network: You pay nothingOut-of-Network: 30% coinsurance
In-Network: $40 copayment for routine radiology services Out-of-Network: 30% coinsurance for routine radiology services
Services with a (1) may require prior authorization.
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Hearing Services
• Hearing Exam
• Hearing Aid
In-Network: $40 copayment for Medicare-covered
hearing exams received from a Preferred specialist
$50 copayment for Medicare-covered hearing exams
received from a Standard specialist
Out-of-Network: 30% coinsurance after deductible for
Medicare-covered hearing exams
Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment for
routine non-Medicare-covered hearing exams once every
year.
Available with Choice: In-Network and
Out-of-network: $699 standard digital hearing aid or
$999 premium digital hearing aid copayment per year,
per ear; 3 hearing aid fitting and evaluations every year;
up to 2 hearing aids every year, one hearing aid per ear.
Available with Choice Plus: In-Network and Out-of-
Network: $499 standard digital hearing aid or $799
premium digital hearing aid copayment per year, per
ear; 3 hearing aid fittings per year; up to 2 hearing aids
every year, one hearing aid per ear.
Routine hearing services and aids are covered when
provided by a TruHearing provider. Routine hearing
services do not count towards annual MOOP.
In-Network: $40 copayment for Medicare-covered
hearing exams
Out-of-Network: 30% coinsurance for Medi-
care-covered hearing exams
Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment
for routine non-Medicare-covered hearing exams
once every year.
Available with Choice: In-Network and
Out-of-network: $699 standard digital hearing aid
or $999 premium digital hearing aid copayment per
year, per ear; 3 hearing aid fittings per year; up to 2
hearing aids every year, one hearing aid per ear.
Available with Choice Plus: In-Network and Out-of-
Network: $499 standard digital hearing aid or $799
premium digital hearing aid copayment per year, per
ear; 3 hearing aid fittings per year up to 2 hearing
aids every year, one hearing aid per ear.
Routine hearing services and aids are covered when
provided by a TruHearing provider. Routine hearing
services do not count towards annual MOOP.
In-Network: $40 copayment for Medicare-cov-
ered hearing exams
Out-of-Network: 30% coinsurance for Medi-
care-covered hearing exams
Available with Choice or Choice Plus: In-Network
and Out-of-Network: $10 copayment for routine
non-Medicare-covered hearing exams once every
year.
Available with Choice: In-Network and Out-of-
Network: $699 standard digital hearing aid or
$999 premium digital hearing aid copayment per
year, per ear; 3 hearing aid fittings per year; up to
2 hearing aids every year, one hearing aid per ear.
Available with Choice Plus: In-Network and
Out-of-Network: $499 standard digital hearing
aid or $799 premium digital hearing aid copay-
ment per year, per ear; 3 hearing aid
fittings per year; up to 2 hearing aids every year,
one hearing aid per ear.
Routine hearing services and aids are covered
when provided by a TruHearing provider.
Routine hearing services do not count towards
annual MOOP.
Services with a (1) may require prior authorization.
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Hearing Services
• Hearing Exam
• Hearing Aid
In-Network: $40 copayment for Medicare-covered
hearing exams received from a Preferred specialist
$50 copayment for Medicare-covered hearing exams
received from a Standard specialist
Out-of-Network: 30% coinsurance after deductible for
Medicare-covered hearing exams
Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment for
routine non-Medicare-covered hearing exams once every
year.
Available with Choice: In-Network and
Out-of-network: $699 standard digital hearing aid or
$999 premium digital hearing aid copayment per year,
per ear; 3 hearing aid fitting and evaluations every year;
up to 2 hearing aids every year, one hearing aid per ear.
Available with Choice Plus: In-Network and Out-of-
Network: $499 standard digital hearing aid or $799
premium digital hearing aid copayment per year, per
ear; 3 hearing aid fittings per year; up to 2 hearing aids
every year, one hearing aid per ear.
Routine hearing services and aids are covered when
provided by a TruHearing provider. Routine hearing
services do not count towards annual MOOP.
In-Network: $40 copayment for Medicare-covered
hearing exams
Out-of-Network: 30% coinsurance for Medi-
care-covered hearing exams
Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment
for routine non-Medicare-covered hearing exams
once every year.
Available with Choice: In-Network and
Out-of-network: $699 standard digital hearing aid
or $999 premium digital hearing aid copayment per
year, per ear; 3 hearing aid fittings per year; up to 2
hearing aids every year, one hearing aid per ear.
Available with Choice Plus: In-Network and Out-of-
Network: $499 standard digital hearing aid or $799
premium digital hearing aid copayment per year, per
ear; 3 hearing aid fittings per year up to 2 hearing
aids every year, one hearing aid per ear.
Routine hearing services and aids are covered when
provided by a TruHearing provider. Routine hearing
services do not count towards annual MOOP.
In-Network: $40 copayment for Medicare-cov-
ered hearing exams
Out-of-Network: 30% coinsurance for Medi-
care-covered hearing exams
Available with Choice or Choice Plus: In-Network
and Out-of-Network: $10 copayment for routine
non-Medicare-covered hearing exams once every
year.
Available with Choice: In-Network and Out-of-
Network: $699 standard digital hearing aid or
$999 premium digital hearing aid copayment per
year, per ear; 3 hearing aid fittings per year; up to
2 hearing aids every year, one hearing aid per ear.
Available with Choice Plus: In-Network and
Out-of-Network: $499 standard digital hearing
aid or $799 premium digital hearing aid copay-
ment per year, per ear; 3 hearing aid
fittings per year; up to 2 hearing aids every year,
one hearing aid per ear.
Routine hearing services and aids are covered
when provided by a TruHearing provider.
Routine hearing services do not count towards
annual MOOP.
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Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Dental Services In-Network: $40 copayment for non-routine Medicare-covered dental services in a Preferred specialist office; $50 copayment for Medicare-covered dental services received from a Standard specialist
Out-of-Network: 30% coinsurance after deductible for non-routine Medicare-covered dental services in a specialist office
Available through Choice: In-Network: $10 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodontics, periodontics, and extractions
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
80% coinsurance for restorative services, endodontics, periodontics, and extractions
$500 combined plan allowance every year for restorative dental services, endodontics, periodontics, and extractions.
Prosthodontics and oral surgery are not covered
Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
$1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
80% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
In-Network: $40 copayment for non-routine Medi-care-covered dental services in a specialist office
Out-of-Network: 30% coinsurance for non-routine Medicare-covered dental services in a specialist office
Available through Choice: In-Network: $10 copay-ment for routine non-Medicare-covered exam and cleaning every six months
$0 copayment for 1 set of dental bite-wing x-rays ev-ery year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodon-tics, periodontics, and extractions
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services and dental X-rays
80% coinsurance for restorative services, endodon-tics, periodontics, and extractions
$500 combined plan allowance every year for re-storative dental services, endodontics, periodontics, and extractions.
Prosthodontics and oral surgery are not covered
Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodon-tics, periodontics, extractions, prosthodontics, and oral surgery
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
$1500 combined in- and out-of-network plan allow-ance every year for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
80% coinsurance for restorative services, endodon-tics, periodontics, extractions, prosthodontics, and oral surgery
In-Network: $40 copayment for non-routine Medicare-covered dental services in a specialist office
Out-of-Network: 30% coinsurance for non-rou-tine Medicare-covered dental services in a spe-cialist office
Available through Choice: In-Network: $10 co-payment for routine non-Medicare-covered exam and cleaning every six months
$0 copayment for 1 set of dental bite-wing x-rays ev-ery year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, end-odontics, periodontics, and extractions
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services and dental X-rays
80% coinsurance for restorative services, end-odontics, periodontics, and extractions
$500 combined plan allowance every year for restorative dental services, endodontics, periodon-tics, and extractions.
Prosthodontics and oral surgery are not covered
Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, end-odontics, periodontics, extractions, prosthodon-tics, and oral surgery
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
$1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics, periodontics, extractions, prostho-dontics, and oral surgery
80% coinsurance for restorative services, end-odontics, periodontics, extractions, prosthodon-tics, and oral surgery
14 15
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Dental Services In-Network: $40 copayment for non-routine Medicare-covered dental services in a Preferred specialist office; $50 copayment for Medicare-covered dental services received from a Standard specialist
Out-of-Network: 30% coinsurance after deductible for non-routine Medicare-covered dental services in a specialist office
Available through Choice: In-Network: $10 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodontics, periodontics, and extractions
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
80% coinsurance for restorative services, endodontics, periodontics, and extractions
$500 combined plan allowance every year for restorative dental services, endodontics, periodontics, and extractions.
Prosthodontics and oral surgery are not covered
Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
$1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
80% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
In-Network: $40 copayment for non-routine Medi-care-covered dental services in a specialist office
Out-of-Network: 30% coinsurance for non-routine Medicare-covered dental services in a specialist office
Available through Choice: In-Network: $10 copay-ment for routine non-Medicare-covered exam and cleaning every six months
$0 copayment for 1 set of dental bite-wing x-rays ev-ery year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodon-tics, periodontics, and extractions
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services and dental X-rays
80% coinsurance for restorative services, endodon-tics, periodontics, and extractions
$500 combined plan allowance every year for re-storative dental services, endodontics, periodontics, and extractions.
Prosthodontics and oral surgery are not covered
Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, endodon-tics, periodontics, extractions, prosthodontics, and oral surgery
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
$1500 combined in- and out-of-network plan allow-ance every year for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery
80% coinsurance for restorative services, endodon-tics, periodontics, extractions, prosthodontics, and oral surgery
In-Network: $40 copayment for non-routine Medicare-covered dental services in a specialist office
Out-of-Network: 30% coinsurance for non-rou-tine Medicare-covered dental services in a spe-cialist office
Available through Choice: In-Network: $10 co-payment for routine non-Medicare-covered exam and cleaning every six months
$0 copayment for 1 set of dental bite-wing x-rays ev-ery year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, end-odontics, periodontics, and extractions
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services and dental X-rays
80% coinsurance for restorative services, end-odontics, periodontics, and extractions
$500 combined plan allowance every year for restorative dental services, endodontics, periodon-tics, and extractions.
Prosthodontics and oral surgery are not covered
Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months
$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered
50% coinsurance for restorative services, end-odontics, periodontics, extractions, prosthodon-tics, and oral surgery
Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services
$1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics, periodontics, extractions, prostho-dontics, and oral surgery
80% coinsurance for restorative services, end-odontics, periodontics, extractions, prosthodon-tics, and oral surgery
16 17Services with a (1) may require prior authorization.
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Vision Services In-Network: $40 copayment for Medicare-covered
eye exams received from a Preferred specialist, $50
copayment for Medicare-covered eye exams received
from a Standard specialist; $0 copayment for diabetic
retinal eye exam and $0 copayment for Medicare-
covered glaucoma screening; $0 copayment for one pair
of Medicare-covered eyeglasses or contact lenses after
cataract surgery
Out-of-Network: 30% coinsurance after deductible for
Medicare-covered eye exams, diabetic retinal exam,
glaucoma screening and for one pair of eyeglasses or
contact lenses after cataract surgery
Available through Choice or Choice Plus: $10 copayment for routine eye exam every year; 1 pair
of eyeglass frames and lenses or one pair of contact
lenses are covered in full every year if purchased from
the Davis Vision Collection;
$150 combined in- and out-of-network plan allowance
every year for all other eyewear
(glasses, lenses or contacts) purchased at a
Davis Vision provider.
$200 combined in- and out-of-network allowance every
year for eyewear (glasses and lenses) purchased from
Visionworks.
Routine vision services do not count towards the annual
MOOP.
Out-of-Network: 80% coinsurance
In-Network: $40 copayment for Medicare-covered eye
exams; $0 copayment for diabetic retinal eye exam and
$0 copayment for Medicare-covered glaucoma screening;
$0 copayment for one pair of Medicare-covered
eyeglasses or contact lenses after cataract surgery
Out-of-Network: 30% coinsurance for Medicare-covered
eye exams, diabetic retinal exam, glaucoma screening and
for one pair of eyeglasses or contact lenses after cataract
surgery
Available through Choice or Choice Plus: $10 copayment for routine eye exam every year; 1 pair
of eyeglass frames and lenses or one pair of contact
lenses are covered in full every year if purchased from
the Davis Vision Collection;
$150 combined in- and out-of-network plan allowance
every year for all other eyewear
(glasses, lenses or contacts) purchased at a
Davis Vision provider.
$200 combined in- and out-of-network plan allowance
every year for eyewear (glasses and lenses) purchased
from Visionworks.
Routine vision services do not count towards the annual
MOOP.
Out-of-Network: 80% coinsurance
In-Network: $40 copayment for Medicare-covered eye
exams; $0 copayment for diabetic retinal eye exam and $0
copayment for Medicare-covered glaucoma screening; $0
copayment for one pair of Medicare-covered eyeglasses or
contact lenses after cataract surgery
Out-of-Network: 30% coinsurance for Medicare-covered
eye exams, diabetic retinal exam, glaucoma screening
and for one pair of eyeglasses or contact lenses after
cataract surgery
Available through Choice or Choice Plus: $10 copayment for routine eye exam every year;
1 pair of eyeglass frames and lenses or one pair
of contact lenses are covered in full every year
if purchased from the Davis Vision Collection;
$150 combined in- and out-of-network plan allowance
every year for all other eyewear
(glasses, lenses or contacts) purchased at a
Davis Vision provider.
$200 combined in- and out-of-network plan allowance
every year for eyewear (glasses and lenses) purchased
from Visionworks.
Routine vision services do not count towards the
annual MOOP.
Out-of-Network: 80% coinsurance
16 17
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Vision Services In-Network: $40 copayment for Medicare-covered
eye exams received from a Preferred specialist, $50
copayment for Medicare-covered eye exams received
from a Standard specialist; $0 copayment for diabetic
retinal eye exam and $0 copayment for Medicare-
covered glaucoma screening; $0 copayment for one pair
of Medicare-covered eyeglasses or contact lenses after
cataract surgery
Out-of-Network: 30% coinsurance after deductible for
Medicare-covered eye exams, diabetic retinal exam,
glaucoma screening and for one pair of eyeglasses or
contact lenses after cataract surgery
Available through Choice or Choice Plus: $10 copayment for routine eye exam every year; 1 pair
of eyeglass frames and lenses or one pair of contact
lenses are covered in full every year if purchased from
the Davis Vision Collection;
$150 combined in- and out-of-network plan allowance
every year for all other eyewear
(glasses, lenses or contacts) purchased at a
Davis Vision provider.
$200 combined in- and out-of-network allowance every
year for eyewear (glasses and lenses) purchased from
Visionworks.
Routine vision services do not count towards the annual
MOOP.
Out-of-Network: 80% coinsurance
In-Network: $40 copayment for Medicare-covered eye
exams; $0 copayment for diabetic retinal eye exam and
$0 copayment for Medicare-covered glaucoma screening;
$0 copayment for one pair of Medicare-covered
eyeglasses or contact lenses after cataract surgery
Out-of-Network: 30% coinsurance for Medicare-covered
eye exams, diabetic retinal exam, glaucoma screening and
for one pair of eyeglasses or contact lenses after cataract
surgery
Available through Choice or Choice Plus: $10 copayment for routine eye exam every year; 1 pair
of eyeglass frames and lenses or one pair of contact
lenses are covered in full every year if purchased from
the Davis Vision Collection;
$150 combined in- and out-of-network plan allowance
every year for all other eyewear
(glasses, lenses or contacts) purchased at a
Davis Vision provider.
$200 combined in- and out-of-network plan allowance
every year for eyewear (glasses and lenses) purchased
from Visionworks.
Routine vision services do not count towards the annual
MOOP.
Out-of-Network: 80% coinsurance
In-Network: $40 copayment for Medicare-covered eye
exams; $0 copayment for diabetic retinal eye exam and $0
copayment for Medicare-covered glaucoma screening; $0
copayment for one pair of Medicare-covered eyeglasses or
contact lenses after cataract surgery
Out-of-Network: 30% coinsurance for Medicare-covered
eye exams, diabetic retinal exam, glaucoma screening
and for one pair of eyeglasses or contact lenses after
cataract surgery
Available through Choice or Choice Plus: $10 copayment for routine eye exam every year;
1 pair of eyeglass frames and lenses or one pair
of contact lenses are covered in full every year
if purchased from the Davis Vision Collection;
$150 combined in- and out-of-network plan allowance
every year for all other eyewear
(glasses, lenses or contacts) purchased at a
Davis Vision provider.
$200 combined in- and out-of-network plan allowance
every year for eyewear (glasses and lenses) purchased
from Visionworks.
Routine vision services do not count towards the
annual MOOP.
Out-of-Network: 80% coinsurance
18 19
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Mental Health Services
• Inpatient Mental Health Care (2)
• Outpatient Therapy (Group and Individual)
• Outpatient Substance Abuse Services (Group and Individual)
• Partial Hospitalization (2)
In-Network: $250 copayment per day for Preferred
Hospital for days 1 through 5 per admission
$310 copayment per day for Standard Hospital for days 1
through 5 per admission
You pay nothing per day for days 6 and beyond
Out-of-Network: 30% coinsurance after deductible
190-day lifetime maximum in a mental health facility
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance after deductible
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance after deductible
In-Network: $40 copayment per visit
Out-of-Network: 30% coinsurance after deductible
In-Network: $250 copayment per day for days
1 through 6 per admission.
You pay nothing per day for days 7 and beyond
Out-of-Network: 30% coinsurance
$1,500 maximum copayment per admission
190-day lifetime maximum in a mental health facility
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance
In-Network: $40 copayment per visit
Out-of-Network: 30% coinsurance
In-Network: $250 copayment per day for days 1
through 6 per admission.
You pay nothing per day for days 7 and beyond Out-of-Network: 30% coinsurance
$1,500 maximum copayment per admission 190-day lifetime maximum in a mental health facility
In-Network: $40 copayment per therapy session Out-of-Network: 30% coinsurance
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance
In-Network: $40 copayment per visit
Out-of-Network: 30% coinsurance
Skilled Nursing Facility (1) In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance after deductible per day for days 1 through 100100 days per benefit period
In-Network: You pay nothing per day for days 1 through 20$165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period
In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period
Physical Therapy In-Network: $30 copayment per visit Out-of-Network: 30% coinsurance per visit after deductible
In-Network: $20 copayment per visitOut-of-Network: 30% coinsurance per visit
In-Network: $20 copayment per visit Out-of-Network: 30% coinsurance per visit
Ambulance (1) $300 copayment for a one-way trip
Not waived if admitted
Non-emergency ambulance services require prior
authorization
$175 copayment for a one-way trip
Not waived if admitted
Non-emergency ambulance services require prior
authorization
$175 copayment for a one-way trip
Not waived if admitted
Non-emergency ambulance services require prior
authorization
Transportation Not covered Not covered Not covered
Services with a (1) may require prior authorization. (2) Prior authorization is required by Magellan Behavioral Health.
18 19
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Mental Health Services
• Inpatient Mental Health Care (2)
• Outpatient Therapy (Group and Individual)
• Outpatient Substance Abuse Services (Group and Individual)
• Partial Hospitalization (2)
In-Network: $250 copayment per day for Preferred
Hospital for days 1 through 5 per admission
$310 copayment per day for Standard Hospital for days 1
through 5 per admission
You pay nothing per day for days 6 and beyond
Out-of-Network: 30% coinsurance after deductible
190-day lifetime maximum in a mental health facility
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance after deductible
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance after deductible
In-Network: $40 copayment per visit
Out-of-Network: 30% coinsurance after deductible
In-Network: $250 copayment per day for days
1 through 6 per admission.
You pay nothing per day for days 7 and beyond
Out-of-Network: 30% coinsurance
$1,500 maximum copayment per admission
190-day lifetime maximum in a mental health facility
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance
In-Network: $40 copayment per visit
Out-of-Network: 30% coinsurance
In-Network: $250 copayment per day for days 1
through 6 per admission.
You pay nothing per day for days 7 and beyond Out-of-Network: 30% coinsurance
$1,500 maximum copayment per admission 190-day lifetime maximum in a mental health facility
In-Network: $40 copayment per therapy session Out-of-Network: 30% coinsurance
In-Network: $40 copayment per therapy session
Out-of-Network: 30% coinsurance
In-Network: $40 copayment per visit
Out-of-Network: 30% coinsurance
Skilled Nursing Facility (1) In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance after deductible per day for days 1 through 100100 days per benefit period
In-Network: You pay nothing per day for days 1 through 20$165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period
In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period
Physical Therapy In-Network: $30 copayment per visit Out-of-Network: 30% coinsurance per visit after deductible
In-Network: $20 copayment per visitOut-of-Network: 30% coinsurance per visit
In-Network: $20 copayment per visit Out-of-Network: 30% coinsurance per visit
Ambulance (1) $300 copayment for a one-way trip
Not waived if admitted
Non-emergency ambulance services require prior
authorization
$175 copayment for a one-way trip
Not waived if admitted
Non-emergency ambulance services require prior
authorization
$175 copayment for a one-way trip
Not waived if admitted
Non-emergency ambulance services require prior
authorization
Transportation Not covered Not covered Not covered
20 21Services with a (1) may require prior authorization.
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Medicare Part B Drugs (1) In-Network: 20% coinsurance for Part B drugs such as
chemotherapy drugs
Out-of-Network: 30% coinsurance for Part B drugs such
as chemotherapy drugs
For a description of the types of drugs available under
Part B, see your Evidence of Coverage
In-Network: 20% coinsurance for Part B drugs such as
chemotherapy drugs
Out-of-Network: 30% coinsurance for Part B drugs such
as chemotherapy drugs
For a description of the types of drugs available under
Part B, see your Evidence of Coverage
In-Network: 20% coinsurance for Part B drugs such
as chemotherapy drugs
Out-of-Network: 30% coinsurance for Part B drugs
such as chemotherapy drugs
For a description of the types of drugs available under
Part B, see your Evidence of Coverage
Prescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Personal Choice 65 Rx PPO and Personal Choice 65 Prime Rx PPO. This benefit is not available for members of Personal Choice 65SM Medical-Only PPO.
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Initial Coverage Stage You pay the following until your total yearly drug costs
reach $4,020. “Total yearly drug costs” are the total drug
costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and
mail-order pharmacies.
Cost-sharing may change depending on the pharmacy
you choose and when you move into each stage of your
Part D benefits. You may fill your prescriptions at
either a preferred or standard pharmacy. Tier 1 and 2
prescriptions (which include most generic drugs) will have
lower copayments when you have them filled at preferred
pharmacies. For information, please review the Personal
Choice 65SM Prime Rx PPO Evidence of Coverage.
Part D prescription drugs are not available with this
plan.
You pay the following until your total yearly drug costs
reach $4,020. “Total yearly drug costs” are the total
drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies
and mail-order pharmacies.
Cost-sharing may change depending on the pharmacy
you choose and when you move into
each stage of your Part D benefits. You may fill
your prescriptions at either a preferred or
standard pharmacy. Tier 1 and 2 prescriptions (which
include most generic drugs) will have lower copayments
when you have them filled at preferred pharmacies. For
information, please review the Personal Choice 65SM
Rx PPO Evidence of Coverage.
20 21
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Medicare Part B Drugs (1) In-Network: 20% coinsurance for Part B drugs such as
chemotherapy drugs
Out-of-Network: 30% coinsurance for Part B drugs such
as chemotherapy drugs
For a description of the types of drugs available under
Part B, see your Evidence of Coverage
In-Network: 20% coinsurance for Part B drugs such as
chemotherapy drugs
Out-of-Network: 30% coinsurance for Part B drugs such
as chemotherapy drugs
For a description of the types of drugs available under
Part B, see your Evidence of Coverage
In-Network: 20% coinsurance for Part B drugs such
as chemotherapy drugs
Out-of-Network: 30% coinsurance for Part B drugs
such as chemotherapy drugs
For a description of the types of drugs available under
Part B, see your Evidence of Coverage
Prescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Personal Choice 65 Rx PPO and Personal Choice 65 Prime Rx PPO. This benefit is not available for members of Personal Choice 65SM Medical-Only PPO.
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Initial Coverage Stage You pay the following until your total yearly drug costs
reach $4,020. “Total yearly drug costs” are the total drug
costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and
mail-order pharmacies.
Cost-sharing may change depending on the pharmacy
you choose and when you move into each stage of your
Part D benefits. You may fill your prescriptions at
either a preferred or standard pharmacy. Tier 1 and 2
prescriptions (which include most generic drugs) will have
lower copayments when you have them filled at preferred
pharmacies. For information, please review the Personal
Choice 65SM Prime Rx PPO Evidence of Coverage.
Part D prescription drugs are not available with this
plan.
You pay the following until your total yearly drug costs
reach $4,020. “Total yearly drug costs” are the total
drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies
and mail-order pharmacies.
Cost-sharing may change depending on the pharmacy
you choose and when you move into
each stage of your Part D benefits. You may fill
your prescriptions at either a preferred or
standard pharmacy. Tier 1 and 2 prescriptions (which
include most generic drugs) will have lower copayments
when you have them filled at preferred pharmacies. For
information, please review the Personal Choice 65SM
Rx PPO Evidence of Coverage.
22 23
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Retail Cost-sharing (what you pay at a pharmacy location)
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
Tier 1 (Preferred Generic Drugs)
Preferred Pharmacy Standard Pharmacy
$2 copayment
$9 copayment
$4 copayment
$18 copayment
$4 copayment
$27 copayment
Part D prescription drugs are not available with this
plan.
$1 copayment
$9 copayment
$2 copayment
$18 copayment
$2 copayment
$27 copayment
Tier 2 (Generic Drugs)
Preferred Pharmacy Standard Pharmacy
$10 copayment
$20 copayment
$20 copayment
$40 copayment
$20 copayment
$60 copayment
Part D prescription drugs are not available with this
plan.
$9 copayment
$20 copayment
$18 copayment
$40 copayment
$18 copayment
$60 copayment
Tier 3 (Preferred Brand Drugs)
Preferred Pharmacy Standard Pharmacy
$47 copayment
$47 copayment
$94 copayment
$94 copayment
$141 copayment
$141 copayment
Part D prescription drugs are not available with this
plan.
$47 copayment
$47 copayment
$94 copayment
$94 copayment
$141 copayment
$141 copayment
Tier 4 (Non-Preferred Drugs)
Preferred Pharmacy Standard Pharmacy
$100 copayment
$100 copayment
$200 copayment
$200 copayment
$300 copayment
$300 copayment
Part D prescription drugs are not available with this
plan.
$100 copayment
$100 copayment
$200 copayment
$200 copay-
ment
$300 copayment
$300 copayment
Tier 5 (Specialty Drugs)
Preferred Pharmacy Standard Pharmacy
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
Part D prescription drugs are not available with this
plan.
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
Mail-Order Cost-sharing (what you pay when you order a prescription by mail)
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
Tier 1 (Preferred Generic Drugs) $2 copayment $4 copayment $4 copayment Part D prescription drugs are not available with this
plan.
$1 copayment $2 copayment $2 copayment
Tier 2 (Generic Drugs) $10 copayment $20 copayment $20 copayment Part D prescription drugs are not available with this
plan.
$9 copayment $18 copayment $18 copayment
Tier 3 (Preferred Brand Drugs) $47 copayment $94 copayment $94 copayment Part D prescription drugs are not available with this
plan.
$47 copayment $94 copayment $94 copayment
Tier 4 (Non-Preferred Drugs) $100 copayment $200 copayment $200 copayment Part D prescription drugs are not available with this
plan.
$100 copay-ment
$200 copay-ment
$200 copayment
Tier 5 (Specialty Drugs) 33% coinsur-ance
33% coinsur-ance
33% coinsurance Part D prescription drugs are not available with this
plan.
33% coinsur-ance
33% coinsur-ance
33% coinsurance
22 23
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Retail Cost-sharing (what you pay at a pharmacy location)
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
Tier 1 (Preferred Generic Drugs)
Preferred Pharmacy Standard Pharmacy
$2 copayment
$9 copayment
$4 copayment
$18 copayment
$4 copayment
$27 copayment
Part D prescription drugs are not available with this
plan.
$1 copayment
$9 copayment
$2 copayment
$18 copayment
$2 copayment
$27 copayment
Tier 2 (Generic Drugs)
Preferred Pharmacy Standard Pharmacy
$10 copayment
$20 copayment
$20 copayment
$40 copayment
$20 copayment
$60 copayment
Part D prescription drugs are not available with this
plan.
$9 copayment
$20 copayment
$18 copayment
$40 copayment
$18 copayment
$60 copayment
Tier 3 (Preferred Brand Drugs)
Preferred Pharmacy Standard Pharmacy
$47 copayment
$47 copayment
$94 copayment
$94 copayment
$141 copayment
$141 copayment
Part D prescription drugs are not available with this
plan.
$47 copayment
$47 copayment
$94 copayment
$94 copayment
$141 copayment
$141 copayment
Tier 4 (Non-Preferred Drugs)
Preferred Pharmacy Standard Pharmacy
$100 copayment
$100 copayment
$200 copayment
$200 copayment
$300 copayment
$300 copayment
Part D prescription drugs are not available with this
plan.
$100 copayment
$100 copayment
$200 copayment
$200 copay-
ment
$300 copayment
$300 copayment
Tier 5 (Specialty Drugs)
Preferred Pharmacy Standard Pharmacy
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
Part D prescription drugs are not available with this
plan.
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
33% coinsurance
Mail-Order Cost-sharing (what you pay when you order a prescription by mail)
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
One-Month
Supply
Two-Month
Supply
Three-Month
Supply
Tier 1 (Preferred Generic Drugs) $2 copayment $4 copayment $4 copayment Part D prescription drugs are not available with this
plan.
$1 copayment $2 copayment $2 copayment
Tier 2 (Generic Drugs) $10 copayment $20 copayment $20 copayment Part D prescription drugs are not available with this
plan.
$9 copayment $18 copayment $18 copayment
Tier 3 (Preferred Brand Drugs) $47 copayment $94 copayment $94 copayment Part D prescription drugs are not available with this
plan.
$47 copayment $94 copayment $94 copayment
Tier 4 (Non-Preferred Drugs) $100 copayment $200 copayment $200 copayment Part D prescription drugs are not available with this
plan.
$100 copay-ment
$200 copay-ment
$200 copayment
Tier 5 (Specialty Drugs) 33% coinsur-ance
33% coinsur-ance
33% coinsurance Part D prescription drugs are not available with this
plan.
33% coinsur-ance
33% coinsur-ance
33% coinsurance
24 25Services with a (1) may require prior authorization.
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Initial Coverage Stage If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Part D prescription drugs are not available with this plan.
If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Part D prescription drugs are not available with this plan.
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the great-er of:
• 5% of the costs, or;
• $3.60 copayment for generic (including brand drugs tested as generic) and an $8.95 copayment for all other drugs
Part D prescription drugs are not available with this plan.
After your yearly out-of-pocket drug costs (includ-ing drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:
• 5% of the costs, or;
• $3.60 copayment for generic (including brand drugs tested as generic) and an $8.95 copayment for all other drugs
Other Medical BenefitsPodiatry Services
• Medical Condition
• Routine Foot Care (Medicare-covered)
• Routine Foot Care (non-Medicare-covered)
In-Network: $25 copayment per visit for condition treatment and $25 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit after deductible for condition treatment and Medicare-covered routine care
In-Network: $25 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine care, up to 6 visits each year
In-Network: $20 copayment per visit for condition treatment and $20 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit for condition treatment and Medicare-covered routine care
In-Network: $20 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine care, up to 6 visits each year
In-Network: $20 copayment per visit for condition treatment and $20 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit for condition treatment and Medicare-covered routine care
In-Network: $20 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine care, up to 6 visits each year
24 25
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Initial Coverage Stage If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Part D prescription drugs are not available with this plan.
If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Part D prescription drugs are not available with this plan.
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the great-er of:
• 5% of the costs, or;
• $3.60 copayment for generic (including brand drugs tested as generic) and an $8.95 copayment for all other drugs
Part D prescription drugs are not available with this plan.
After your yearly out-of-pocket drug costs (includ-ing drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:
• 5% of the costs, or;
• $3.60 copayment for generic (including brand drugs tested as generic) and an $8.95 copayment for all other drugs
Other Medical BenefitsPodiatry Services
• Medical Condition
• Routine Foot Care (Medicare-covered)
• Routine Foot Care (non-Medicare-covered)
In-Network: $25 copayment per visit for condition treatment and $25 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit after deductible for condition treatment and Medicare-covered routine care
In-Network: $25 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine care, up to 6 visits each year
In-Network: $20 copayment per visit for condition treatment and $20 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit for condition treatment and Medicare-covered routine care
In-Network: $20 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine care, up to 6 visits each year
In-Network: $20 copayment per visit for condition treatment and $20 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit for condition treatment and Medicare-covered routine care
In-Network: $20 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine care, up to 6 visits each year
26 27
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Over-the-Counter (OTC) Items In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Allowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharmacies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.
In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Allowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharmacies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.
In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Al-lowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharma-cies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.
Telemedicine In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are avail-able 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-li-censed physicians. Telemedicine services rendered from other providers will not be covered.
In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are avail-able 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-li-censed physicians. Telemedicine services rendered from other providers will not be covered.
In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are available 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-licensed physicians. Telemedicine services rendered from other providers will not be covered.
Diabetic Supplies No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.
No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.
Out-of-network: 30% coinsurance
No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.
No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.
Out-of-network: 30% coinsurance
No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.
No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.
Out-of-network: 30% coinsurance
Chiropractic Services
• Medical-covered (Medicare-covered)
• Routine Care (non-Medicare-covered)
In-Network: $20 copayment per visit for spinal manipulations
Out-of-Network: 30% coinsurance per visit after deductible for spinal manipulations
In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
In-Network: $20 copayment per visit for spinal manipulations
Out-of-Network: 30% coinsurance per visit for spinal manipulations
In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
In-Network: $20 copayment per visit for spinal manipulations
Out-of-Network: 30% coinsurance per visit for spinal manipulations
In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
26 27
Personal Choice 65SM
Prime Rx PPO Personal Choice 65SM
Medical-Only PPO Personal Choice 65SM
Rx PPO
Over-the-Counter (OTC) Items In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Allowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharmacies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.
In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Allowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharmacies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.
In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Al-lowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharma-cies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.
Telemedicine In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are avail-able 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-li-censed physicians. Telemedicine services rendered from other providers will not be covered.
In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are avail-able 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-li-censed physicians. Telemedicine services rendered from other providers will not be covered.
In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are available 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-licensed physicians. Telemedicine services rendered from other providers will not be covered.
Diabetic Supplies No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.
No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.
Out-of-network: 30% coinsurance
No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.
No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.
Out-of-network: 30% coinsurance
No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.
No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.
Out-of-network: 30% coinsurance
Chiropractic Services
• Medical-covered (Medicare-covered)
• Routine Care (non-Medicare-covered)
In-Network: $20 copayment per visit for spinal manipulations
Out-of-Network: 30% coinsurance per visit after deductible for spinal manipulations
In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
In-Network: $20 copayment per visit for spinal manipulations
Out-of-Network: 30% coinsurance per visit for spinal manipulations
In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
In-Network: $20 copayment per visit for spinal manipulations
Out-of-Network: 30% coinsurance per visit for spinal manipulations
In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)
28 29
Pre-Enrollment Checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a Member Help Team representative at 1-888-718-3333 (TTY/TDD: 711).
Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.ibxmedicare.com or call 1-888-718-3333 (TTY/TDD: 711) to view a copy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.
Benefits, premiums and/or copayments/coinsurance may change on January 1, 2021.
Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situation, non-contracted providers may deny care. In addition, you will pay a higher copay for services received by non-contracted providers.
28 29
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30 31
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
Language Assistance Services
Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711).
Chinese: 注意:如果您讲中文,您可以得到免费的语言
协助服务。致电 1-800-275-2583。 Korean: 안내사항: 한국어를 사용하시는 경우, 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-275-2583 번으로 전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para 1-800-275-2583. Gujarati: �ચૂના: જો તમે �જુરાતી બોલતા હો, તો િન:��ુ� ભાષા સહાય સેવાઓ તમારા માટ� ��લ�� છે. 1-800-275-2583 કોલ કરો.
Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi 1-800-275-2583. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Тел.: 1-800-275-2583. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic:
، فإن خدمات المساعدة اللغوية العربية ملحوظة: إذا كنت تتحدث اللغة .2583-275-800-1 اتصل برقملك بالمجان. متاحة
French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583.
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583.
French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-800-275-2583. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. Hindi: �या� द�: यिद आप िहदंी बोलते ह� तो आपके िलए मु�त म� भाषा सहायता सेवाएं �पल�� ह�। कॉल कर� 1-800-275-2583। German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. Japanese: 備考:母国語が日本語の方は、言語アシス
タンスサービス(無料)をご利用いただけます。
1-800-275-2583へお電話ください。
Persian (Farsi): صورت ه ب خدمات ترجمه، فارسی صحبت می کنيدتوجه: اگر
2583-275-800-1با شماره . رايگان برای شما فراھم می باشد .تماس بگيريد
Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. H0d77lnih koj8’ 1-800-275-2583.
Urdu:
توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں، تو آپ کے لئے کال کريں ۔دستياب ہيں مفت ميں زبان معاون خدمات
.1-800-275-2583
Mon-Khmer, Cambodian: សូ�េ��្ត ចប់�រ�មណ៍៖ ្របសិនេបើអនកនិ�យ���ន-ែខមរ ���ែខមរ េនះជំនួយែផនក��នឹងមនផ្តល់ជូនដល់េ�កអនកេ�យ�តគិតៃថ្ល។ ទូរសពទេទេលខ 1-800-275-2583។
30 31
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
Language Assistance Services
Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711).
Chinese: 注意:如果您讲中文,您可以得到免费的语言
协助服务。致电 1-800-275-2583。 Korean: 안내사항: 한국어를 사용하시는 경우, 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-275-2583 번으로 전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para 1-800-275-2583. Gujarati: �ચૂના: જો તમે �જુરાતી બોલતા હો, તો િન:��ુ� ભાષા સહાય સેવાઓ તમારા માટ� ��લ�� છે. 1-800-275-2583 કોલ કરો.
Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi 1-800-275-2583. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Тел.: 1-800-275-2583. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic:
، فإن خدمات المساعدة اللغوية العربية ملحوظة: إذا كنت تتحدث اللغة .2583-275-800-1 اتصل برقملك بالمجان. متاحة
French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583.
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583.
French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-800-275-2583. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. Hindi: �या� द�: यिद आप िहदंी बोलते ह� तो आपके िलए मु�त म� भाषा सहायता सेवाएं �पल�� ह�। कॉल कर� 1-800-275-2583। German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. Japanese: 備考:母国語が日本語の方は、言語アシス
タンスサービス(無料)をご利用いただけます。
1-800-275-2583へお電話ください。
Persian (Farsi): صورت ه ب خدمات ترجمه، فارسی صحبت می کنيدتوجه: اگر
2583-275-800-1با شماره . رايگان برای شما فراھم می باشد .تماس بگيريد
Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. H0d77lnih koj8’ 1-800-275-2583.
Urdu:
توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں، تو آپ کے لئے کال کريں ۔دستياب ہيں مفت ميں زبان معاون خدمات
.1-800-275-2583
Mon-Khmer, Cambodian: សូ�េ��្ត ចប់�រ�មណ៍៖ ្របសិនេបើអនកនិ�យ���ន-ែខមរ ���ែខមរ េនះជំនួយែផនក��នឹងមនផ្តល់ជូនដល់េ�កអនកេ�យ�តគិតៃថ្ល។ ទូរសពទេទេលខ 1-800-275-2583។
Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016
Discrimination is Against the Law
This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
This Plan provides: Free aids and services to people with disabilities
to communicate effectively with us, such as:qualified sign language interpreters, and writteninformation in other formats (large print, audio,accessible electronic formats, other formats).
Free language services to people whoseprimary language is not English, such as:qualified interpreters and information written inother languages.
If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market St reet , Ph i lade lph ia , PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email: [email protected]. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
IBC7756 (10/16)
32 PB
PO Box 13713Philadelphia, PA 19101-3713
www.ibxmedicare.com
For more informationFor updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call theMember Help Team at 1-888-718-3333 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. Please note thaton weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD: 711,seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 throughSeptember 30, your call may be sent to voicemail. By calling this number you will be directed to a licensedsales agent.
Personal Choice 65 offers PPO plans with a Medicare contract. Enrollment in Personal Choice 65 MedicareAdvantage plans depends on contract renewal.
TruHearing® is a registered trademark of TruHearing, Inc., an independent company.
Vision benefits are underwritten by Keystone Health Plan East and administered by Davis Vision, an indepen-dent company.
An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company.
The Independence OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered byConvey Health Solutions, Inc., an independent company.
Telemedicine is provided by MDLIVE, an independent company.
To receive this document in an alternate format such as Braille, large print, or audio, please call1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed sales agent) or1-888-718-3333 (members) (TTY/TDD: 711).
This information is not a complete description of benefits. Contact 1-877-393-6733 for more information.
Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 Medical-OnlyPPO or Personal Choice 65 Rx PPO members, except in emergency situations. For a decision about whether wewill cover an out-of-network service, we encourage you or your provider to ask us for a pre-serviceorganization determination before you receive the service. Please call our customer service number orsee your Evidence of Coverage for more information, including the cost-sharing that applies toout-of-network services.
Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross —independent licensees of the Blue Cross and Blue Shield Association.
PC8888 (8/18)
PO Box 13713Philadelphia, PA 19101-3713
www.ibxmedicare.com
For more informationFor updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call theMember Help Team at 1-888-718-3333 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. Please note thaton weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD: 711,seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 throughSeptember 30, your call may be sent to voicemail. By calling this number you will be directed to a licensedsales agent.
Personal Choice 65 offers PPO plans with a Medicare contract. Enrollment in Personal Choice 65 MedicareAdvantage plans depends on contract renewal.
TruHearing® is a registered trademark of TruHearing, Inc., an independent company.
Vision benefits are underwritten by Keystone Health Plan East and administered by Davis Vision, an indepen-dent company.
An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company.
The Independence OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered byConvey Health Solutions, Inc., an independent company.
Telemedicine is provided by MDLIVE, an independent company.
To receive this document in an alternate format such as Braille, large print, or audio, please call1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed sales agent) or1-888-718-3333 (members) (TTY/TDD: 711).
This information is not a complete description of benefits. Contact 1-877-393-6733 for more information.
Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 Medical-OnlyPPO or Personal Choice 65 Rx PPO members, except in emergency situations. For a decision about whether wewill cover an out-of-network service, we encourage you or your provider to ask us for a pre-serviceorganization determination before you receive the service. Please call our customer service number orsee your Evidence of Coverage for more information, including the cost-sharing that applies toout-of-network services.
Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross —independent licensees of the Blue Cross and Blue Shield Association.
PC8888 (8/18)
For more informationFor updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call the Member Help Team at 1-888-718-3333 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD: 711, seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail. By calling this number you will be directed to a licensed sales agent.
Personal Choice 65 offers PPO plans with a Medicare contract. Enrollment in Personal Choice 65 Medicare Advantage plans depends on contract renewal.
TruHearing® is a registered trademark of TruHearing, Inc., an independent company.
Vision benefits are underwritten by QCC Insurance Company and administered by Davis Vision, an independent company.
An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company.
The Independence Blue Cross Over the Counter benefit is underwritten by QCC Insurance Company and is admin-istered by Convey Health Solutions, Inc., an independent company.
To receive this document in an alternate format such as Braille, large print, or audio, please call 1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed sales agent) or 1-888-718-3333 (members) (TTY/TDD: 711).
This information is not a complete description of benefits. Contact 1-877-393-6733 for more information.
Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.
Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 Prime Rx PPO, Personal Choice 65 Medical-Only PPO, or Personal Choice 65 Rx PPO members, except in emergency situa-tions. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.
PC8888 (8/18)